Have we got it all wrong?

Since the work of Emil Kraepelin, mental health or illness has dominated western society. The last decade has seen a 13% increase in mental health and substance use conditions, with around 20% of the world’s children and adolescents being given a mental health condition. In fact, the more that psychiatric theory and practice are promoted, the worse humanity’s mental health becomes. This is not a conspiracy theory. The recent work of Joanna Moncrieff has proven unequivocally that what we thought we knew about depression was wrong. So, could we have gotten it all wrong if we got that wrong? This is a tricky question to ask but also to answer, and I’m not sure if I even have an answer, but I think it’s worth a discussion. If you have read any of my other blogs, you know that I work in the mental health field and love my job. Therefore, by asking the above question, I risk offending some colleagues. This is not my intention. My sole purpose is to offer support and care to those who need it. However, over the decade, it feels like we have been going backwards.

How do we justify or explain such a remarkable rise in mental health disorders? We refer to it as a disease, specifically a brain disease. If this is true, then 792 million people have such a disease. Within the UK, it is estimated that around 45 million people experience symptoms of mental disease in any week. It is caused by neurotransmitter dysregulation, genetic anomalies, and defects in the brain structure and function. Neuroscience dazzles us with pictures of the brain and explains why we are sad, hear voices or are unable to control the fear of something terrible happening. But here comes the kicker: there is no evidence of any biological cause or reliable biomarker for any mental disorder. When I first read this, it ‘blew my head apart’, and I thought it must be wrong. But, if we conceive other diseases, such as type 1 diabetes, a person will weaken and eventually die if they aren’t given an injection of insulin. We know that our immune system breaks down insulin beta cells, and this can be tested through blood tests such as A1C. No such test exists for any common mental health disorder.

So, if there are no tests, how can so many people be diagnosed with such a disorder? Any such disorder is given on the basis of symptoms observed or verbalised by the person experiencing them. The Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fifth edition, was designed to aid diagnosis in creating a scientific diagnostic system. To understand how this works, we need to return to the work of Emil Kraepelin. His textbook in 1883 and eight editions inspired an innovative way of predicting prognosis. However, his most significant contribution was his separation of dementia praecox and psychosis, creating two new diagnoses manic-depression illness and schizophrenia. Kraepelin arguable created the first classification of mental disorder based on clinical observation, which continues to influence writers of the DSM today. What is interesting is that in all editions of the DSM, mental illnesses are continually attributed to biological defects in the hope that such biological defects would be found. From its conception in 1945 to the early 1950s, the DSM was virtually without influence on the international stage. However, the pharmaceutical revolution in the 1950s  and the explosion of new psychopharmacologic agents made the field sit up and take notice of the concept of disease. Further classifications were then made; for instance, Kraepelin’s manic-depression illness was replaced with affective disorders, depression, and mania. An operational criteria was also created for depression a person would need to meet the following, loss of energy, and sleep difficulty, all of which had lasted a least a month. However, what is now fascinating about these criteria is that it was created around a table without any scientific validity. Nevertheless, the notion of the disease continued, and treatment was via pharmaceutical intervention. Using depression as an example: 20.5 million antidepressants were prescribed from April to June 2021, reinforcing the notion that mental health is a disease.

The above is based on the monoamine theory of depression in that low levels of serotonin cause depression. However, as stated above, Moncrieff et al (2022) have found this to be inaccurate. In fact, their comprehensive review found no convincing evidence that depression is associated with, or caused by, lower serotonin levels. Therefore, why have millions and millions of people been taking antidepressants? This is because there is a fundamental problem with the disease model of mental health. It focuses on symptoms as signs, turning transitive phenomena into intransitive phenomena, and consequently, that process of reification becomes an example of the epistemic fallacy. What I mean by this is that by believing that a disease causes mental health, we confuse reality with what we are told is reality. The reality is that mental illness/health is not caused by disease yet; we are told it is, and we believe it is. This is evident in how many of us take antidepressants. Psychiatrists are, therefore, trained to see their role as identifying sick individuals and, in doing so, give a diagnosis; they also predict the future of the illness (prognosis) and speculate about its cause (aetiology) and finally prescribe a response to the condition (treatment). An example of this process is John, who lives in a low economic area of a city, let’s, say, Manchester. He has been unemployed for over a year due to being made redundant. John attends his GPs with the following symptoms, sadness, poor appetite, lack of sleep, lethargy and feeling of being worthless. The GP may skim a diagnosis statistical manual such as DSM, in which they will find a checklist. With the above six symptoms, John would be positive for a diagnosis of depression, and treatment would be biological in nature. Therefore, he would leave with a prescription for antidepressants. But the cause of his depression isn’t a chemical imbalance, we now know that. Could it be that he is sad because of where he lives, losing his job and a loss of purpose?

Another example is Sarah, who lives with her two children. She separated from her husband, the children’s father, ten years ago due to ongoing domestic abuse. However, her ex-husband continued to psychologically abuse her. Sarah attempted to end her life as she could no longer live with the abuse from her husband. On seeing a mental health professional, Sarah was told that she was depressed and needed to start an antidepressant. Her children were also removed from her care due to her attempting to end her life. She was also told by children’s services if she didn’t take the antidepressants, she would not get her children back. This is based on the chemical imbalance hypothesis of depression which we now know is wrong. So instead of an antidepressant, would it not be more beneficial to address the abuse from her husband, as this was the reason she tried to end her life? By saying that Sarah has a chemical imbalance that has caused her to be depressed, we are masking, in fact, blatantly ignoring the abuse she has sustained. In essence, we are blaming Sarah.

An alternative view

A person who walks down the road talking to themselves or talking to someone standing next to them that no one else can see has been judged to be different. The person who has experienced a horrendous trauma and is now unable to leave the house for fear of something terrible happening again is deemed different. The person who marks their body through self-harm or attempts to end their life is considered different. We now live in an individualist society, one in which those that are unable to conform to societal norms are seen as different, often given a mental disorder. But, mental disorders, as outlined in the DSM, do not exist; instead, people exist, distressed, dysfunctional, and unintelligible at times, but they are still people. As well as an individualist society, we live in an unequal society. Poor education, food banks, lack of service provision and poor housing often dominate the lives of people diagnosed with a mental disorder. Would they have been given such a disorder if they didn’t live in such an unequal society? For the last 15 years, we’ve lived and suffered under capitalism, its biggest contradiction being as the rich get richer, the poor get poorer. Could it not be the case that this enforced inequality is the cause of mental distress? Or have we become a society reliant on a pill to solve all our woes? We have become so medicalised in our thinking that our basic human emotions are now pathologised, categorised and medicalised. What if we accept differences for what it is a uniqueness like no other? Yes, people will still experience mental distress, and they will still need the support of mental health professionals, but what if that support was focused on “what had happened to them” instead of seeing them as the problem that needs fixing? An impossibility, you say, but why is it? The death of a loved one or the ending of a relationship is traumatic, in fact, dam right horrible. But one of the most normal emotions is a sense of loss. Instead of taking pills to numb these feelings, we work on accepting them and embracing them even. We develop a protective circle around the person that harnesses empowerment and empathy, instill a sense of purpose again, and ultimately gives hope. You may think this is idealistic, but it’s only idealistic because of our current way of thinking. The next ten years will see a significant change in the field of mental health, and we need alternate views, so let’s start now! Any thoughts?